How user friendly is your outpatient department?

A GUIDE FOR IMPROVING SERVICES

This information is also available as a printed booklet with illustrations

ROYAL COLLEGE OF PHYSICIANS

Introduction
This booklet was commissioned by the Royal College of Physicians following a joint Working Party of the College and the NHS Confederation that examined the organisation of medical outpatient departments. It is designed to help medical outpatient clinics provide a more user-friendly service. Each section has a checklist, which may be used by staff to assess how patient friendly their service is. A few of the proposals may need extra resources but many are already part of current practice. We hope this booklet will support healthcare professionals by making suggestions that will help patients: the aim is to put patients at their ease and to provide a better service.

CONTENTS
Section 1 The outpatient clinic 3 Information provided before an appointment 4 Finding the clinic 5 Arrival and welcome 5 Appointments 6 Waiting times 7 Management of patients who fail to attend 7 Waiting areas 8 Staff 9 Team-working and skillmix 10 Patients with disabilities 10 Checklist 11 Section 2 Communication 13 Written information and advance communication 14 Other methods of communication 15 Consistency of communication 16 Checklist 17 Section 3 Before and during the consultation 19 Clinic planning 20 Maintaining dignity and privacy 20 The consultation 21 At the end of the consultation 22 Teaching and training in the outpatient department 22 Checklist 24 Section 4 Results and follow-up 25 Results and follow-up plans 26 Side effects 27 Checklist 27 Section 5 Reviewing patient-friendly policies 29 Appendix Members of the Working Party 31

This guide was prepared by the Royal College of Physicians following a Working Party of the College and the NHS Confederation that examined the organisation of medical outpatient departments. It is adapted from earlier documents produced by the Royal College of Radiologists (RCR) Clinical Radiology Patients Liaison Group, and the RCR Clinical Oncology Patients Liaison Group, whose lay members experiences formed the basis of the original documents.

ROYAL COLLEGE OF PHYSICIANS 11 St Andrews Place, London NW1 4LE www.rcplondon.ac.uk Registered Charity No 210508 Copyright 2004 Royal College of Physicians of London ISBN 1 86016 199 5

Text and layout by the RCP Publications Unit

SECTION 1

The outpatient clinic

S S S S S S S S S S S Information provided before an appointment 4 Finding the clinic 5 Arrival and welcome 5 Appointments 6 Waiting times 7 Management of patients who fail to attend 7 Waiting areas 8 Staff 9 Team-working and skillmix 10 Patients with disabilities 10 Checklist 11

Information provided before an appointment

The information supplied to patients and their carers before an appointment is essential in relieving patients anxieties over the pending appointment. It can also reduce the number of patients who fail to attend their appointment.
Correspondence provided prior to an appointment should include: A the time, date and proposed duration of the appointment A direct line telephone numbers of the person to contact if the patient is unable to attend the appointment A direct line telephone numbers, prominently displayed, of the person to contact if the patient is hearing impaired or has language problems that may require the services of an interpreter during the consultation A the telephone number of a helpline operated by a qualified nurse (if this service exists) for those with queries about their appointment A map of the hospital showing the location of the clinic A car parking/transport information, including facilities for disabled people A a reminder about where to report upon arrival at the clinic, eg to main reception A details of who will conduct the appointment, ie specialist registrar, nurse specialist or dietitian, if patients will not always be seen by the supervising consultant A written information about investigations and procedures that may be undertaken A suggestions of suitable clothing to wear, if relevant A details of any requirements that must be fulfilled before or during the appointment, such as providing a urine sample A advice regarding whether patients should fast A a reminder to bring details of current medication and of any additional pending or current referrals, investigations or treatments the patient may also be receiving A information about whether medical students may be present.

In addition, in some cases: A If a preliminary diagnosis suggests strongly that bad news will have to be given to the patient at the appointment, the patient should be encouraged to bring a chaperone, friend or relative. A If it is likely that investigations requiring written consent will be undertaken, a consent form should be included; this will reduce delays at the clinic.

Finding the clinic

Hospitals can be intimidating places for patients. If visitors can reach the correct clinic with minimum confusion, this will reduce anxiety and be less tiring for them. A department may be located across more than one site and patients will need to know where to go.
A Each site should be clearly signposted from the main entrance and on all relevant corridors and parts of the building. A A map of the hospital site is vital. The clinic must be clearly marked. A The nearest drop-off and pick-up point to the clinic should also be marked on the map. A Car parking spaces for patients with disabilities should be available and clearly signposted in the car park.

Arrival and welcome

The reception desk is the first point of contact that patients have with your clinic. Their first impression will influence their attitude to the clinic and their appointment.
Reception areas are often busy places. Reception staff have to deal with queries that come in by phone and in person, as well as making appointments and directing patients. Computerised booking systems usually require time and concentration, often leaving reception staff with less time to deal with patients.

A To reduce patients apprehension, there should always be a friendly and efficient person available to greet them, to give them information and attend to any needs they may have. A To ensure that someone is available to greet patients properly, it may help to separate the tasks and the areas used for welcoming patients and for booking appointments. A If separating the areas is impossible and reception staff are too busy to provide a more personal system, perhaps a volunteer could help with greeting patients and providing basic information. Sources of volunteers include support groups, ex-patients, the Womens Royal Voluntary Service and the Hospital League of Friends. A It may be useful for reception staff to attend a clinical induction course where the various procedures are explained to them, so that they will have a good understanding of patients needs. A Staff should ask patients how they wish to be addressed, and should not assume, for example, that first names are acceptable. A Each patients demographic data should be checked on every visit to outpatients, no matter how often the patient has attended.

Appointments
Patients may prefer to have appointments at specific times of the day to help them continue with a daily routine and to meet other demands. It is also important to explain why appointments may not be available at certain times.
A As set out in the NHS Plan, an appointments system of full or partial pre-booking should be used to give patients a choice of appointment time. A Patients may have days or times which are much less convenient for them than others, and this should be taken into consideration if possible. A Patients using public or ambulance transport may have certain requirements which should be considered. A When the clinic has to change appointment times, try to give patients as much notice as possible.

A The direct telephone number of the clinic should be on all information sent to patients. If patients find they cannot get through on the appointments line, its availability could be subjected to audit. A Patients should also understand that it is important to let the clinic know if they cannot keep an appointment.

Waiting times
Giving patients information about how long they may wait is considerate and helpful. Waiting longer than expected may make patients anxious, particularly if they have had no warning, or if they believe they have missed their turn.
A Waiting times should not usually exceed 30 minutes. A It is important that reception staff are kept informed about any delays and that this information is passed on to patients on arrival. A If there are any delays that occur after patients initial arrival and during the waiting time, they should be told as soon as possible, so that if necessary they can rearrange their transport or take care of other matters, such as childcare or work arrangements. A The use of digital display boards may assist in providing information about waiting times in particularly busy clinics. A Doctors should make every effort to start outpatient clinics on time. A Patients who arrive late can disrupt an orderly clinic, but their appointment time can often be filled by those who arrive early. As a last resort, it may be necessary to give late arrivals a new appointment. A Waiting times for both inpatients and outpatients should be monitored.

Management of patients who fail to attend

Even in the best-run outpatient clinics, there will always be a small number of patients who fail to attend (Did Not Attend DNA) their appointments. The use of effective booking systems can minimise the DNA rate and the associated loss of clinic capacity, but there

should be a system in place for management of patients who fail to attend without prior notification. Such a system must strike a balance between handling patients sensitively and ensuring that clinics do not become inefficient as a result of repeated patient DNAs.
A Ensure that all clinic staff are aware of local policies on management of DNAs. These policies should be available from the hospital trust. A There should be provision for the notes of patients who DNA to be reviewed by the consultant after the clinic, and a decision made as to whether a further appointment should be offered. A Records should be kept of DNA levels and these should be reviewed regularly and benchmarked. A Patient surveys can provide valuable insight as to the reasons why patients fail to attend. A If a patient does not keep a first appointment, the GP should be informed by letter and a copy of that letter should be sent to the patient.

Waiting areas
Waiting areas should be warm, comfortable and, preferably, have plenty of space.
A Children should have a separate area with toys, books and games. A Pay phones and refreshment areas should be provided and be clearly signposted. A Toilet and baby-changing facilities should be nearby and again be clearly signposted. A Recent magazines and other reading material should be available, as well as information about the clinic and up-to-date general health leaflets. Information about the clinic should be presented in an accessible format and in relevant community languages. Information about national and local patient organisations relevant to the clinic should also be available.

A It is probably safe for people to use mobile telephones in most outpatient clinics, and allowing this may put patients at ease. A There should be a suggestions box, as well as information about how to make comments or complaints.

Staff
Patients may need to know about the different categories of professionals working in the clinic. Patients may not know the exact role of the doctor, nurse or helper in diagnosing and treating many conditions.
A All staff should wear clearly legible badges, showing their name and job title. A It may help to have a whos who clearly displayed, depending on the security policy of the hospital. In larger clinics, this may not be practical, so an information sheet giving a description of the different categories of staff would help. A The senior member of staff in the clinic for any specified day should be identified; for example, by using a sign on a notice board in the reception area. A If professionals from other departments are present in the clinic, they should be identifiable as such. A Displaying the name of the doctor and the nurse on the consultation room door can assist patients in recalling who they will be seeing. A Some departments use specialty-specific signs, eg hypertension clinic, coeliac clinic; this can cause patients unnecessary embarrassment and should therefore be discouraged.

Team-working and skillmix

An efficient, well-run outpatients clinic is dependent on all members of the team, eg doctors, receptionists, lead nurses, technicians. All staff working within the clinic must be aware of their own remit and that of their colleagues.
A All staff working within the outpatients clinic should be consulted when operational procedures are reviewed. A Comprehensive induction programmes should be arranged for new members of staff joining the department. A Outpatient departments should regularly review which member of the clinical team actually sees the different groups of patients. Under the supervision of the lead consultant, many nurses, physiotherapists and dietitians now lead outpatient clinic lists, thus ensuring the most efficient use of consultants time and improving the patient experience. A Good secretarial support is an essential part of outpatient teamwork.

Patients with disabilities

A It is important to let patients know about special facilities that are available for those with disabilities, including accessible toilets and wheelchair access. A There should be enough space in waiting areas and toilets not only for patients in wheelchairs, but also for helpers/carers to manoeuvre wheelchairs in those areas. A Clinics will also need to consider the visibility and availability of signs and facilities for people with different types of sensory deprivation.

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CHECKLIST The outpatient clinic Are patients given the direct telephone number of the person to contact if they are unable to attend their appointment? Is a site map sent to patients? Are the various facilities and sites clearly signposted? Are waiting times usually no longer than 30 minutes? Are waiting times regularly monitored? Are patients informed about possible delays on arrival? Does your clinic have a childrens waiting area? Does your clinic have magazines for patients who are waiting? Is there an induction course for reception staff? Is information available about your clinic in community languages and accessible formats? Is there a whos who or similar information sheet available? Are parking for those with disabilities and wheelchair access points signposted? Are there special facilities for those with sensory deprivation?

Yes

No

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SECTION 2

Communication
S S S S Written information and advance communication 14 Other methods of communication 15 Consistency of communication 16 Checklist 17

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Written information and advance communication

Many new patients will have little information about their clinic visit and may be very nervous about it or its implications. It is important that they are given clear and timely information to read. The following information should be provided in addition to the information given to patients before their appointment as outlined in Section 1, pages 45.

Leaflets
Well-written patient information leaflets are a good means of communicating. They should always be dated and should include the following information: A how long the patient is likely to spend in the clinic A what advance preparations the patient should make; for example, the clinic may require a diary/list of symptoms in advance A whether patients need to bring a list of the drugs they are currently taking A whether students are likely to be present A whether anything apart from a standard consultation is likely to take place, eg sigmoidoscopy or insertion of eye drops A whether the patient should be fasting A whether patients will need to undress A reassurance that a chaperone will be present if an intimate examination is necessary A whether patients will need someone to accompany them, and that they will be notified of this in advance A whether patients will be able to drive/return to work immediately afterwards A relevant, up-to-date, accessible information about the condition A the helpline telephone number, operated by a qualified nurse, for patients with queries about their appointment.

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Patient groups should be invited to assist in the drafting of any new patient information, in order to aid accessibility. Where possible, information leaflets should also be checked for plain English, or hold a Crystal Mark for clarity of English.

The Internet
Patients may also obtain information from the Internet. The Royal College of Physicians website (www.rcplondon.ac.uk) will be providing a range of patient information with links to relevant specialist societies in mid 2004. The NHS Direct website (www.nhsdirect.nhs.uk) may also be helpful. An information bulletin board directing patients to useful Internet sites and contacts for national and local patient organisations has been shown to help patients.

Communicating the risks and the benefits

Patients need to have enough information to decide whether to give their informed consent for treatment, as described in Good medical practice (General Medical Council, 2001). They need to be able to understand any risks and to weigh these against the benefits before attending their appointment. A If the patient has been referred for further investigation or treatment, provide information about this. A If possible, provide details of useful contacts both in the hospital and elsewhere (eg patient support groups).

Other methods of communication

All patients need to have information about their appointment and investigations. Some patients cannot read or may not be able to read English. It is important that these patients have the same information as those who can read the materials given to them. The needs of the deaf, and people who are hard of hearing or visually impaired should also be taken into account.
A Videos, tape-recordings and CD-ROMs can be used to give the same information as printed pamphlets and books.

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A Use drawings and photographs as much as possible, as they can provide useful ways of giving the same information as leaflets. They can be particularly helpful for children. A Patients who do not have English as their first language may need to have written information in their own language. A Translating and interpreting services may be needed. Before the patients first appointment, make sure you know their first language and, if it is not English, whether they need interpretation services.

Consistency of communication
There will be several healthcare professionals involved in dealing with an individual patient in the clinic. Consistent communication between team members and the delivery of clear information are essential in order to avoid conflicting information and advice being given to patients or their relatives.
A Consider setting up a standard protocol within the clinic for issuing reports. This should state how long after the appointment the report will arrive, when it will reach the referring clinician and how that clinician will then contact the patient. A All healthcare professionals involved in the care of a patient should agree on the follow-up instructions they will give the patient, so that conflict and confusion are avoided. A Patients should be included in any discussions held in their presence about them and their condition or diagnosis. A It is important that all healthcare professionals can demonstrate good skills in dealing with people and in communication.

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CHECKLIST Communication Does your patient information literature deal with the following: What will happen during the appointment? How long will the appointment take? Are patients always informed in advance of the nature of the visit? Are patients informed about which member(s) of the team they will be seeing? Are patients given instructions about driving/operating machinery/returning to work? Does your clinic have information in languages other than English, and in accessible formats? Can you obtain the help of signers and interpreters if necessary? Is all written information dated? Have staff received communication skills training?

Yes

No

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SECTION 3

Before and during the consultation

S Clinic planning 20 S Maintaining dignity and privacy 20 S The consultation 21 S At the end of the consultation 22 S Teaching and training in the outpatient department 22 S Checklist 24

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Clinic planning
Planning clinic appointments on a daily, weekly and monthly basis can make a real difference to both patients and clinic staff. Work done by the NHS Modernisation Agency has demonstrated the improvements that can be made by reviewing the patient pathway and reducing the number of steps involved. For example, tests can be carried out and results conveyed to the patient on one outpatient visit.
All information relevant to the patient should be available to the team before the appointment, so that no time is wasted during the consultation searching for reports, results etc. A The notes of all new patients should be reviewed by the consultant prior to the clinic and agreement reached as to which member of the clinical team will see each patient. A All results of tests ordered at previous appointments should be available to the medical team. A The scope for one-stop (or reduced stop) clinics for each clinical specialty should be explored. A Wherever possible, patients preferences for a health professional of a specific gender should be met.

Maintaining dignity and privacy

Many patients feel self-conscious, insecure and vulnerable during an examination, although they may not wish to admit to these feelings. It is important that staff are sensitive to this, and that they take steps to preserve the dignity and privacy of every patient.
A When patients are required to change into a gown, do not ask them to do so in front of staff unless assistance from a helper is required. Whenever possible, the patient must be allowed to remove or adjust their own clothing or gown, with assistance only provided at the request of the patient, or with their agreement.

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A Every patient has the right to a chaperone; this may be a clinic nurse or a friend. If a patient declines or refuses a chaperone this should be noted in the records. A Staff, eg clerks or nurses, should be strongly discouraged from entering the room during a consultation; a strict knock and wait policy should be in operation.

The consultation
A Consultations should take place in privacy and without interruption. A Only essential staff should be present in the room. It is distressing for patients to have people in the room who have not been introduced and whose role and function they do not know or understand. All the staff in the room should introduce themselves and explain their roles. A The senior specialist should describe what will be done and make sure that the patient agrees and understands. A Once an examination has started, anyone who is not directly involved should not enter the room. A There are many examinations where patients may need to be partially dressed. In order to maintain the patients dignity, healthcare professionals should make sure that the patient is not left naked or unnecessarily exposed; for example, when intimate examinations are carried out or if staff need to leave the room while results are being processed or reviewed. A When examining children, it is helpful if the parent or carer stays with the child. A If assistance is needed, then the patient should be informed, and the new member of staff introduced when entering the room. A Discussions between staff about other patients should be held only out of the patients earshot. It is unsettling for patients undergoing an examination to think that the professionals mind is elsewhere. A During the examination, it is helpful for patients if staff inform them about what will happen next and what the patient will feel. This can reduce apprehension, and patients will be reassured if they know that they can tell staff if they become too uncomfortable.

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A It may help to tell patients in advance roughly how long the examination will last, as well as informing them during it how much longer it will take. A Some patients may need assistance to get on and off the examination couch.

At the end of the consultation

A The patient will need to know whether a follow-up appointment in the same clinic is necessary, and how to make that appointment. A Many patients require a set of blood tests, and this may involve severe delays. A Patients may need to obtain drugs from the hospital pharmacy, and the dispensing often involves delays. A The patient may be expected to make a series of new appointments for procedures in other departments for example, X-ray, cardiology, nuclear medicine or endoscopy. This can result in a confusing and daunting journey unless these departments are clearly signposted from the clinic, or maps to them are provided in outpatients.

Teaching and training in the outpatient department

Outpatient experience is an important part of training for health professionals but from the patients point of view this needs to be handled sensitively to minimise intrusion and avoid creating additional anxiety.
A If patients are likely to meet students in an outpatient clinic, this should be mentioned in the letter about their first appointment. Patients should be offered the opportunity to decline to take part in teaching, and it should be emphasised that this will have no effect on the treatment they will receive. A If, on arrival at the clinic, a patient may be seen with students present, the opportunity to decline to participate should be explained, without the students present. The patient should be made aware that a decision to participate can be revoked at any point.

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A If students are present at the consultation, then they should be introduced to the patient at the beginning, with a clear explanation as to who they are and why they are there. A further enquiry as to whether the patient has any objection to them being present should be made. A The room and people within it should be organised so as to minimise the disruption to the consultation. Numbers of students should be limited; in most cases a single extra person should be the maximum. A The content of teaching in the presence of the patient should be circumscribed to avoid inappropriate and/or distressing information being discussed. A If the student is to do anything more than observe, eg practise a technique, then the patient should be asked for permission beforehand. A If a patient has objections to having students present this should be noted and, if possible, further enquiries should be avoided at follow-up appointments. A dot on the case notes could be used to convey this information. A Clinic timings should take account of the time likely to be spent on teaching so that realistic appointment times can be given.

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CHECKLIST Before and during the consultation Do you try to meet the patients preference for gender of practitioner? Are patients given facilities where they can undress discreetly? Is the privacy and dignity of the patient always maintained? Do you have a written protocol on staff not interrupting during consultations, except in an emergency? Do you follow the recommendations in Good medical practice (General Medical Council, 2001) when carrying out intimate examinations? Is it easy for patients to make follow-up appointments in your clinic? Does your outpatient blood-testing service often result in severe delays? Does your outpatient pharmacy have unreasonable delays in dispensing? How easy is it for patients to make appointments for procedures in other departments? Are patients informed in their appointment letter that they may meet medical students in the outpatient clinic? Are patients offered the opportunity to decline to take part in teaching?

Yes

No

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SECTION 4

Results and follow-up

S Results and follow-up plans 26 S Side effects 27 S Checklist 27

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Results and follow-up plans

Patients want to know the results of the consultation and any tests as soon as possible. The waiting period can be a worrying time and some may think that modern equipment should provide quick results. Patients might know they cannot have a full report straight away but many hope to receive an all-clear or information about whether or not examination or test results appear normal immediately after the appointment. It is important to clarify follow-up plans with patients before they leave the clinic, so that they have the opportunity to ask questions about future care or other concerns.
A If tests have been organised, then patients should be told when and how they will be informed of the results. Before they leave the clinic, they need to know what their follow-up plan is. If a further appointment is necessary, they should know this and how it will be arranged. If no follow-up is planned, then this should be explained to patients and a clear plan of what they should do next be communicated to them. A If medication is prescribed, then it should be made clear whether this is a course, eg of antibiotics, or whether the patient will need to get a further supply either from the clinic or from their GP. A It is often helpful to review the follow-up plan with the patient at the very end of the visit, listing tests, treatment and follow-up plans. This will provide an opportunity for the patient to ask any final questions or raise any concerns. For some patients, a written plan will be helpful. A If a confirmed diagnosis has been made, patients should be given information about local and national patient organisations that can provide further information and discuss patients concerns. A A private area should be available where counselling can take place if required. A The results of the consultation are usually sent in a letter to the GP. A copy of this letter should normally be sent to the patient, with a note to explain that it is written in medical terms.

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A The patients daytime phone number especially mobile phone number should be recorded in the notes to allow quick reassurance, or recall, if needed.

Side effects
If patients have been prescribed medication, they need to be made aware of how they are likely to feel whilst taking the medication, and of the possibility of any side effects.
A Patients should be given clear information, both written and verbal, about side effects. A Patients need to know who to contact if they do become ill or have a reaction to the medication. A Patients should be given clear instructions about driving, operating machinery, returning to work, etc.

CHECKLIST Results and follow-up Are your patients given clear information about follow-up arrangements? Do patients receive clear instructions about prescribed medication? Do you provide up-to-date information on patient organisations (both local and national)? Is there a private area where counselling can take place? Do you send your patients a copy of the letter to their GP? Do you note the patients (mobile) phone number? Are patients told in advance of any possible side effects of prescribed medication? Do patients know who to contact if they become ill whilst taking prescribed medication?

Yes

No

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SECTION 5

Reviewing patientfriendly policies

A real test of the effectiveness of your department is through the views of your patients. They have information that no one else can give you. You do not need to carry out large surveys of all aspects of investigations and procedures in your clinic. You could decide to focus on a certain area one year and perhaps carry out a survey of another area the following year. Most people will feel pleased to be consulted about their experiences and happy to contribute to improving services for others.

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A Consider setting up a local patients liaison group or user group to get regular feedback about specific aspects of your service. You could use this group to help implement improvements and possibly monitor your performance. A Ask staff members to suggest changes they think would improve the well-being of patients. A A suggestions box should be visible at the clinic reception for obtaining direct feedback from patients. A Many organisations, eg the Commission for Health Audit and Inspection, the Audit Commission, Disabled Users etc, regularly conduct surveys of outpatient clinics. Departments should actively participate in these surveys and respond to their findings.

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APPENDIX

Members of the Working Party

Roy Pounder MD DSc(Med) FRCP (Chair) Clinical Vice-President, Royal College of Physicians (RCP) Jane Austin Primary Care Manager, NHS Confederation Ron Calvert Executive Director of Operations, University Hospitals of Leicester NHS Trust Maggie Carson BN RGN MSc Research Sister, Endocrine Unit, Edinburgh Royal Infirmary Giles Dunnill MD FRCP RCP New Consultants Committee Nigel Edwards Director of Policy, NHS Confederation Sophie Edwards Chief Executive, Arthritis and Musculoskeletal Alliance Gary Fereday Policy Manager, NHS Confederation Margaret Goose Chief Executive, The Stroke Association Christine Gratus Chair, Clinical Oncology Patients Liaison Group, Royal College of Radiologists Roger Hall MD FRCP Professor of Clinical Cardiology, Hammersmith Hospital David Haslam FRCGP Chairman of Council, Royal College of General Practitioners Pauline Jeffreys BA Outpatient Improvement Manager, Cardiff and Vale NHS Trust Gren Kershaw Chief Executive, Conwy and Denbighshire NHS Trust Nick Morrish MD FRCP Endocrinology and Diabetes Consultant, Bedford Hospital Hugh Rogers BChir National Clinical Lead, Modernisation Agency, Improvement Partnership for Hospitals, London David Vicary FRCP RCP Standing Committee of General Practitioners BJ Waltho BSc RN RM General Manager, House Records and Outpatients, Royal Bournemouth Hospital

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